Appendicitis, or inflammation of the appendix, is one of the most common abdominal conditions requiring emergency surgery. This article explores the causes of weight loss following an appendectomy, a surgical procedure to remove the appendix.
Appendectomy: Procedure and Recovery
Most appendectomies occur within 24 hours of an appendicitis diagnosis. Prior to surgery, an IV line is placed for antibiotic administration, which continues post-surgery for one to seven days, depending on the infection's severity. Additional tests like blood tests or imaging scans may be necessary. Patients must avoid eating and drinking for eight hours before surgery, receiving fluids through the IV line. An anesthesiologist administers general anesthesia, and a tube is placed to monitor breathing.
There are two types of appendectomy:
- Laparoscopic Appendectomy: The surgeon makes one to three small incisions near the belly button, inserting a port and cannula. Carbon dioxide gas inflates the belly for clearer views with a laparoscope. The appendix is tied off, detached, and removed.
- Open Appendectomy: The surgeon makes one larger incision in the lower right abdomen, opening the abdominal cavity. Infection is drained, and the cavity is rinsed with sterile saline. The appendix is tied off, detached, and removed. A drainage tube may be left in the belly if peritonitis is present.
On average, appendix removal takes about one hour. Recovery varies; laparoscopic appendectomy patients may go home the same day, while those with a ruptured appendix or open surgery may stay in the hospital longer.
Appetite Loss After Appendectomy
"Doctor, I have lost my appetite." This is a complaint every surgeon faces daily in their clinical practice. Appetite loss is a common problem after major abdominal surgery, associated with increased morbidity and reduced quality of life. Recent studies demonstrate the influence of reduced gastric volume and ghrelin secretion, and increased satiety hormone secretion.
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Appetite relates to subjective experience and the perception of physical and hedonic hunger. Therefore, similar to pain, appetite assessment is highly subjective. However, the consequences of appetite loss, such as malnutrition, weight loss, or a decrease in serum albumin, are all amenable to objective assessment.
From a physiological perspective, Davis et al described 4 phases in normal appetite signaling. Apart from hormonal influence within the gastrointestinal tract, the hypothalamus, the brain’s central control region responsible for appetite regulation, is also closely connected to higher-order neural circuits involved in food reward, affect, and memory processing. Hedonic hunger, for example, can increase the desire to eat, even in the absence of physiological hunger.
Regarding the psychological perspective on postoperative appetite loss, Wainwright et al performed in-depth interviews with patients after esophagectomy. These patients experienced surgery as a bodily disruption leading, among other effects, to a loss of appetite with appetite either reduced or completely absent for several weeks or longer after surgery.
From the neurophysiological perspective, the hormone ghrelin plays a central role in appetite regulation. A number of studies have investigated postoperative changes in ghrelin levels. In this context, however, appetite and ghrelin levels showed only a weak positive correlation. In a study with a median time of 6 years after subtotal or total gastrectomy, ghrelin plasma levels were still lower than in healthy controls before and after a test meal. Furthermore, healthy controls experienced a transient decrease in ghrelin plasma levels, whereas gastrectomy patients did not. In a second study, Jeon et al found a rapid compensatory mechanism after two-thirds distal gastrectomy. Total ghrelin levels decreased after surgery, with a nadir at 70% 1 hour after surgery, while the active form of ghrelin increased to 135% of preoperative values. Another study supported the finding that subtotal gastrectomy patients experienced less of a decline in ghrelin levels immediately after surgery than total gastrectomy patients did. Seven days after the operation, ghrelin plasma levels decreased by 37% in subtotal versus 47% in total gastrectomy for cancer. Thus, the preservation of at least parts of the stomach may result in a lower decline of ghrelin levels and appetite loss. The abovementioned positive influence of stomach preservation is in line with findings related to ghrelin changes after esoph-agectomy with gastric reconstruction. This procedure resulted in a reduction of 50% in ghrelin plasma levels, compared to reductions of 88% in total gastrectomy, 50% in two-thirds distal gastrectomy, and no change in colectomy when measurements were taken 3 and 7 days after surgery. Koizumi et al found that both appetite and ghrelin plasma levels decreased 1 month after esoph-agectomy, with both recovering approximately 1 year postopera-tively.
Whereas reduced ghrelin levels may cause appetite loss, it may also be caused by an exaggeration of satiety hormones. Dehes-tani and le Roux reviewed the role of the small bowel in unintentional postoperative weight loss. They describe the rapid progress of food into and through the small bowel after upper gastrointestinal surgery as a cause leading to the adaptation of small bowel mucosa and increased secretion of satiety gut hormones such as GLP-1 with a similar effect on satiety caused by bile entering the small bowel faster. Reduced bowel motility may be another source of appetite loss. Tomita et al found that the absence of interdigestive migrating motor complex phase III, that is, a group of contractile waves of the gastrointestinal tract migrating in an oral-anal direction during fasting, correlated highly with appetite loss after gastric surgery. Where interdigestive migrating motor complex phase III was present, patients reported almost no loss of appetite. Its absence correlated with appetite loss in the majority of patients.
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Appetite and appetite loss are subjective sensations, similar to pain. Thus appetite loss is a vastly different problem than surgical complications, such as delayed gastric emptying. The latter can be measured objectively, by nasogastric tube output, or by scintigraphy.
By far the most commonly reported measurement method of appetite loss is the quality of life questionnaire of the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30, n = 54 studies). It consists of 30 items and is composed of multi-item scales and single items and reflects multiple dimensions of quality of life. Patients need about 11 minutes to fill out the questionnaire. Seven items ask binary (yes/no) questions about physical functions. Twenty-one questions measure symptom occurrence over the past week, on a 4-point Likert scale with the options “not at all,” “a little,” “quite a bit,” and “very much.” Question 13 addresses appetite by asking “Have you lacked appetite?.” Two questions ask about general quality of life on a 7-point Likert scale from “1 - very poor” to “7 - excellent.” In contrast, other standardized questionnaires can measure appetite loss, but have rarely been used to measure appetite loss within the studies included in this review. Another commonly used and more precise method of measuring appetite (loss) is the visual analog scale (VAS). Their method is especially suited to monitoring short-term changes in appetite before and after meals. A VAS of 100 mm length with words anchored at each end for the most negative and positive ratings was used. Appetite was thereby measured in different dimensions, that is, hunger (“How hungry do you feel?”), satiety (“How satisfied do you feel?”), fullness (“How full do you feel?”), and prospective food consumption (“How much do you think you can eat?”). Additionally, multi-dimensional approaches to appetite measurement, such as that of Flint et al, reflect another challenge: the difficulty of distinguishing between hunger and appetite. Few studies explore quality of life in surgical patients by means of semi-structured in-depth interviews.
Treatment Options for Appetite Loss
- Gum Chewing: In a meta-analysis of 4 randomized controlled trials gum chewing reduced time to first hunger by 21.2 hours among patients who had bowel surgery.
- Other reported treatment options with positive effects on appetite but lower levels of evidence include, among others, intravenous ghrelin administration, the oral Japanese herbal medicine Rikkunshito, oral mosapride citrate, multidisciplin-ary-counseling, and watching cooking shows.
GLP-1 Receptor Agonists and Appendicitis
While glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have become increasingly prescribed, use is often inhibited by the gastrointestinal adverse effects that patients must endure. Nausea, vomiting, and cholelithiasis are most commonly associated with use, with little to no data or labeling reflecting risk of appendicitis or associated symptoms. Appendicitis etiology is theorized to develop secondary to obstruction of the vermiform via infection or fecalith causing an increase in intraluminal pressure. It is hypothesized that given the aforementioned gastrointestinal effects associated with GLP-1 RAs, patients taking such agents may be more at risk for developing this acute condition.
While minimal data are available to suggest significant causation between GLP-1 RAs and appendicitis, a literature and database search revealed that instances may be more common than previously thought.
As previously mentioned, appendicitis etiology is not fully understood, but fecalith and subsequent increased intraluminal pressure of the surrounding area may result in inflammatory and infectious processes such as the case described herein. Gastrointestinal side effects, particularly constipation, are hallmark adverse reactions associated with this class of medications and it may be hypothesized that chronic suffering from such could ultimately lead to acute appendicitis symptoms.
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With the knowledge collected from this case and the associated literature search, we recommend that caution of these agents be used when determining whether patients with gastrointestinal histories such as constipation, gastroparesis are present. In patients who are started and begin to suffer from gastrointestinal side effects, it may be more prudent to either stop the GLP-1 RA or treat the symptoms associated with reduced gastric motility in an effort to prevent acute conditions such as that described today.
The many benefits of GLP-1 RAs (ie, weight loss, cardioprotection, renal benefits) make these agents increasingly popular among patients with and without diabetes. While the Naranjo score for association does not prove causality, it was interesting to identify that there were in fact incidences of appendicitis occurring in clinical trials but not published in final manuscripts given the small sample affected. Furthermore, nonregulated online forums and forms of social media have indicated an increased commentary around similar adverse events shortly after starting these agents. While the verbiage and details of these cases are less than ideal for investigation, it is an interesting concept to broach as more of society turns to Internet forums for camaraderie surrounding disease states and related experiences.
Dietary Adjustments After Appendectomy
Your appendix doesn’t play a major role in digestion, so you may not need to make any lasting changes to your diet after surgery. However, there may be foods to avoid after appendix surgery to limit abdominal pain and ease digestion. Talk with your doctor or a registered dietitian about your diet needs after surgery and during your recovery.
Appendicitis Recovery: Avoid Solid Foods at First
Right after you wake up from surgery, your doctor will likely let you take small sips of water until you have fully recovered from the anesthesia. Once you’re ready to eat, you may want to start by eating easy-to-digest foods like soups and yogurt, according to University of Wisconsin Health.
After abdominal surgery, you may have a hard time digesting regular food. So, your doctor may suggest that you follow a full liquid diet, which is made up of liquids and foods that turn to liquid at room temperature. Meals on a liquid diet might include smoothies, soups, shakes, broth, gelatin, and ice pops, according to Mayo Clinic.
You have to avoid solid food while you’re on the liquid diet. That includes any food that you’d need to chew, including:
- Whole fruits and vegetables
- Meats, poultry, and fish
- Eggs
- Beans
- Bread
- Cold cereal
- Rice and pasta
Your doctor determines when it’s safe for you to start eating regular food after your surgery.
Avoid Foods That Can Cause Constipation
When you get the green light from your doctor, start eating foods that are easy to digest. Some examples are cooked vegetables, soup, rice, bananas, and lean proteins.
Avoid foods that can cause constipation, according to Kaiser Permanente. These foods include:
- Dairy products
- Processed foods like pizza and frozen dinners
- Red meat
- Packaged sweets like cakes, pies, pastries, and donuts
- Caffeinated beverages
Eat Plenty of Fiber
It can take some time for your bowels to return to normal after surgery, according to the National Health Service. It’s important to eat plenty of fiber after surgery once you’re back on solid foods, particularly if you’re taking pain medication that can contribute to constipation.
Foods rich in fiber include:
- Seeds
- Beans
- Various fruits and veggies
- Whole-grains
Be sure to stay hydrated and drink plenty of water, too.
If you’re struggling to eat much after appendix surgery and have constipation as a result, tell your doctor about your symptoms. A healthcare provider may be able to prescribe a stool softener, and help you find food and drinks that you can comfortably consume.
Ease Back Into Your Regular Diet
Appendicitis recovery time depends on what type of surgery you had. According to Cleveland Clinic, there are two types of appendix surgery: A laparoscopic procedure done through a small cut or an open surgery done through a larger cut. Either way, you should be able to go home one day after your operation and recover well enough to return to your normal activities in a couple of weeks.
Once you’re on the road to recovery, eat a balanced diet rich in fruits, vegetables, whole grains, legumes, nuts, and seeds. That can help you get enough daily fiber to meet your needs, which range from 25 to 28 grams (g) per day for women and 28 to 34 g per day for men, according to the American Academy of Nutrition and Dietetics.
Talk with your doctor if you have any questions about returning to a normal diet after appendix surgery. Appendix removal, or an appendectomy, is a common procedure that can bring fast relief from the pain and complications of appendicitis. While recovering, proper nutrition is essential to help your body heal and avoid unnecessary discomfort. Knowing which foods to avoid after appendix removal is a key part of ensuring a smooth and speedy recovery.
After an appendectomy, your digestive system may feel more sensitive as it adjusts to the procedure. Eating the wrong foods can irritate your gut, slow healing, or lead to uncomfortable symptoms like bloating, gas, or diarrhea.
- High-fat, greasy foods like fried chicken, French fries, and doughnuts can be difficult to digest and may cause bloating or discomfort.
- Spicy foods can irritate your digestive system and exacerbate post-surgery symptoms like heartburn or upset stomach.
- While fiber is typically beneficial for digestion, high-fiber foods can be too rough on your system immediately after appendix removal. Foods like raw vegetables, beans, lentils, and whole grains may cause bloating or gas, which can be uncomfortable during recovery.
- Sodas, sparkling water, and other carbonated drinks can cause gas and bloating, adding unnecessary discomfort.
- Some people may experience temporary lactose intolerance after surgery, making it difficult to digest dairy products like milk, cheese, and ice cream. These foods may cause bloating, gas, or diarrhea.
- Sugary snacks, desserts, and sodas can disrupt your gut health and slow your recovery.
- Highly processed foods, such as chips, frozen meals, and packaged snacks, often contain preservatives and additives that can irritate your digestive system.
Foods to Favor After Appendectomy
While it’s important to avoid certain foods, knowing what to eat after appendix removal is just as crucial.
- Stay hydrated with water, clear broths, or herbal teas.
- Pay attention to how your body responds to certain foods.
- Every recovery is unique.
If you experience severe or persistent symptoms such as abdominal pain, vomiting, fever, or difficulty eating, contact your doctor immediately.
General Post-Operative Instructions
Maintaining open communication with your medical team ensures personalized guidance for the optimal healing process. Although many patients will feel a burst of relief once the appendix is removed and initial inflammation subsides, the body has still undergone a significant surgical event.
- 1-2 Weeks of Reduced Activity: Limit strenuous activity such as heavy lifting, running, or high-intensity exercise.
- Incision Care: Keep the incisions clean and dry according to your surgeon’s instructions. A recommended general timeframe is about two weeks of rest, particularly for those who have physically demanding jobs. For some, returning to a desk job or less physically strenuous tasks might be possible within one week, but it’s important to listen to your body and consult with your surgeon for any clarifications.
Additional Considerations
Returning to Work: In general, patients can often resume sedentary jobs within a week or two, especially if most of their day involves sitting and light walking.
Exercise and Physical Activity: Light walking is encouraged soon after surgery, as it promotes circulation and healing. However, strenuous exercises like weightlifting, running, or intense sports should generally be avoided until you receive clearance from your healthcare provider.
Diet Considerations: Keep your diet relatively balanced, focusing on foods that are easy to digest-think soups, steamed vegetables, lean proteins, and whole grains to avoid constipation or bloating.
Listening to Your Body: It’s not uncommon to feel mild twinges or discomfort around your incisions now and then, especially during the healing phase. Pay close attention to any new or worsening pain, and don’t hesitate to contact your physician for advice.
Vitamin C: Clinical investigations have shown that vitamin C plays a vital role in all areas of wound healing, from neutrophil clearance to scab formation.
Zinc-rich foods: Zinc deficiency in the diet might interfere with the body's natural healing mechanism.
Focus on low-fat dairy products: Nature has given us a wonderful healing meal neatly packaged in a shell. All of the nutrients we've already mentioned as being essential for a rapid recovery.
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